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Centene Corporation

Founded as a single health plan in 1984, Centene Corporation (Centene) has established itself as a national leader in the healthcare services field. Today, through a comprehensive portfolio of innovative solutions, we remain deeply committed to delivering results for our stakeholders: state governments, members, providers, uninsured individuals and families, and other healthcare and commercial organizations. Read More

Address      Centene Corporation Centene Plaza 7700 Forsyth Blvd. St. Louis, MO 63105
Website      www.centene.com/
Holding      No Holding Details

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Nurse

Position Purpose:
Facilitate medical necessity appeals and denials including disposition of denials notification letters, review of clinical information to determine if medical necessity criteria are met

Knowledge/Experience:
LPN with 3+ years of clinical nursing experience or RN with 2+ years of clinical nursing experience. Utilization or appeals review experience preferred. Knowledge of InterQual criteria preferred. Proficient with Microsoft Office applications.

Licenses/Certifications: Current state’s RN or LPN license.

Position Responsibilities:

• Review clinical data to determine claim payment based on company policies and National Committee for Quality Assurance (NCQA) guidelines, including overturning denied claims, upholding the denials and submitting cases to the Medical Director for review
• Prepare case review for the Medical Director in cases where criteria are not met based on the additional clinical information received
• Generate appropriate appeal resolution communication to the member and provider in accordance with company policies and NCQA guidelines. Create system authorization events for overturned denial decisions
• Request additional information, as appropriate from provider(s) to facilitate timely appeals resolution
• Gather and prepare case information for Administrative Law Hearings
• Maintain appeals process within the prescribed NCQA timeframes and appeals turnaround database
• Assist the Medical Director with revising, updating and/or creating new policies to satisfy NCQA and contractual requirements

Other Job Information

Vacancy type:

Full Time

Contact Mode:

not provided

Fax:

not provided

Contact Name:

not provided

Job Duration:

not provided

Phone:

(314) 725-4477

Email:

not provided

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